Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, April 7, 2008

The NOTES beat drums louder

Well, Time magazine has decided to bring national exposure to the "NOTES Revolution". In San Diego last month, Drs. Horgan and Talamini removed an appendix (hopefully inflammed) from a healthy 24 year old female via her vagina. For those who haven't heard, Natural Orifice Transendoscopic Surgery (NOTES)is the "next big thing" in general surgery, or so we're told by the innovators. Instead of three ghastly quarter inch incisions on the abdominal wall, surgeons are now exploring the utility of slicing open a woman's vagina for access to the abdominal cavity. Call me crazy but I'm a little skeptical. It sounds so appealing to have "incisionless surgery" but new techniques have to justify that they are as safe as the previous standard of care, improve outcomes, and are justifiable on a cost basis.

Let's look at the typical laparoscopic appendectomy. I make a half inch incision deep on the downslope of your navel. I make a quarter inch incision in your left lower quadrant and another quarter inch incision above the pubic bone (usually in the area covered with pubic hair). Post operatively, I usually have a hard time finding the suprapubic incision (once shaved hair grows back) and the incision by the navel is often obscured by the folds of your belly button. Cosmetically, the result is impressive. Young women have never complained. Parents of children who have it done this way are amazed. So you have to ask yourself: how much better can we get? And are women really going to be excited about having knives flaying open their vaginas? In the article, the patient raves about having minimal pain on post-op day#1 (1-2 on a scale of 10). Well, guess what? My patients will make the same claim for routine, uncomplicated laparoscopic appendecomy. Most return to work in less than five days.

The whole thing strikes me as absurd. This country struggles enough with containment of health care costs. Currently, laparoscopy affords patients the ability to undergo outpatient surgery for conditions such as cholecystitis and appendicitis with minimal morbidity and quick return to normal activity. The cost of hospitals purchasing the equipment required for NOTES, along with the costs of teaching thousands of surgeons how to do it is just mind boggling. If we're going to go down that road, there damn well better be a good reason. And I don't think "women prefer incisionless surgery for cosmetic reasons" is a valid answer.

Laparoscopy revolutionized surgery because, well, it revolutionized the way patients tolerated and recovered from open procedures. An open cholecystectomy would mandate 3-5 days of hospitalization. Plus increased pain. Plus a higher risk of wound complications and hernias. Laparoscopic appendectomy has essentially removed wound infection from the equation, even in perforated cases. Laparoscopic colon resections are reducing hospitalization and post op pain requirements. These are measurable, quantifiable variables. How measurable is something qualitative like "I don't want any scars"? I just don't see the universalization of this procedure happening anytime soon, given our current health care economic climate. It's fine if the really smart doctors at places like Mass General and Mayo Clinic and the like want to work at it and develop expertise, but at some point it should become obvious that the mere "ability to do something" is not justifiable grounds for restructuring how surgical diseases are cured. Take a baseball analogy. Your shortstop is Hanley Ramirez of the Marlins. He bats .300, hits homers, and steals a lot of bases. One of the top two or three SS in the game. But you decide you want someone better. You want Jose Reyes. Maybe he steals a few more bases, score a couple more runs, but overall, his stats are equal to Ramirez. But you want him. You like that he plays for the Mets. You like his "passion" for the game. The problem is, you have to pay twice as much for Jose Reyes. For a guy who gives you essentially the same output as the guy you already have. To get him you have to pay other guys on the team less and sacrifice talent in other spots, like pitching and defense. The advocates for NOTES are like the guy who will trade Hanley Ramirez for a more expensive Jose Reyes. It's crazy. You don't get to the World Series making deals like that. And we won't arrive at a more equitable distribution of health care dollars if we make the big move to NOTES over the next ten years.....

14 comments:

Anonymous
said...

I had an interesting discussion with a third year GI fellow regarding NOTES recently. Two items in the conversation stood out:1- When asked if he thought there was any real advantage to using NOTES, he stated that he recently attended a conference at a major NY academic center where they presented evidence that NOTES causes less hemodynamic compromise under general anesthesia than would laparoscopy. Therefore this may be a preferred method for those with substantial co-morbidities (CAD, CHF, COPD, etc) who are at high-risk for laparoscopy.Two- this particular medicine doctor is very interested in becoming involved with performing NOTES. He is currently finishing his third and last year of GI fellowship, will be doing a GI interventional fellowship next year at a major NY academic center (ERCP), and then will be doing two years of surgical training to become proficient with NOTES. He states that this is the model the medicine/GI docs are seeking to adapt for NOTES training.My reactions: 1- I would like to see the evidence he claims.2- Seems a bit inefficient to undergo NINE years of post-grad training (3 of int med, 3 of GI, 1 interventional, 2 'surgery') so that you can do a procedure most second year surgery residents should feel comfortable with (appy and chole).I agree with everything in your post. Just sharing the info.

Okay, how can appy by NOTES not be considered laparoscopic surgery? How is the appendix visualized for dissection? Surely not but peering through an incised vagina? And, if so, how do you fit a scope and grasper/dissector/scissors and/or stapler all through one hole? I'd rather have an open appy than NOTES!

ha! I just posted about this very same article on my site, but of course, yours is more to the point and has better analogies (baseball). Good to know that even as a med student I wasn't far off the mark on how I read all of this.

I totally agree. If for no other reason, I really cannot imagine patients preferring to have incisions and instruments put through these various orifices, rather than through tiny abdominal incisions. Also, wouldn't you think an incision through a traditionally contaminated area would lead to more intra-abdominal abscesses, despite any prepping? Currently we have qualms about even stapling across a prepped colon - let alone deliberately introducing instruments through it?!

And GI doing surgery? Haven't we already lost enough territory to interventional radiology and cardiology?

Anon-I have heard the same rumor from a younger GI pal of mine. There's a strong push from the GI community to get on board with NOTES early in the game. It would involve some sort of convoluted post-fellowship program where the Gi guy would do a year or two of "surgical training". Just watch where the enthusiasm for this nonsense is going to come from; GI bigwigs on the east coast, not necessarily surgeons.

Enrico-Your post was good. More coherhent than my end of the day ramblings.

Alice- Good point about the wound infection issue. Of course it's a point that's just too obvious for the proponents to care about.

Vaginal surgery is not as easy as people seem to think...closing that incision will be a bitch! And just wait until the post-op vaginal hematomas form. You can betcha I'm not going to care for them. And GI docs caring for it?

Vaginas have a vigorous blood supply...I can forsee a large blood loss. If I don't whipstitch the mucosa during my vag hysts, I routinely get a larger blood loss than my abdominal hysts. That's the way it goes, based on anatomy.

And just wait until they get a woman with bad endometriosis (unsuspected) or prior PID. I hate those cases open.

And, just out of curiosity, how DO they get all of the instruments and camera through 1 hole? I'm just thinking angles of access and mechanical considerations. I'm also thinking about those women who have deep vaginas, who would be a difficult vaginal surgery.

It all just sounds stupid, stupid, stupid. Laparoscopy is quick, minimally invasive (which is why I can't get around DaVinci hysts when we can do laparoscopic hysts), and most importantly, PEOPLE ARE TRAINED IN IT ALREADY!

? surgical training for a GI fellow. Give me a break. With all of the surgical fellows around these days, it's already hard enough to protect us (I'm a 4th year surgical resident). Where will this be done? OR or GI suite? Operating priveleges for gastroenterologists? I do believe NOTES has a role and that surgeons should lead the way. I've operated on enough peri-umbo incisional hernias from "uncomplicated" lap choles to know that even the simple day surgery lap chole doesn't mean the patient is out of the woods. It also may mean - reop for incisional hernia, mesh placement, infected mesh, etc. Curious how many CBD injuries it will take to make peope nervous about NOTES choles however.

? surgical training for a GI fellow. Give me a break. With all of the surgical fellows around these days, it's already hard enough to protect us (I'm a 4th year surgical resident). Where will this be done? OR or GI suite? Operating priveleges for gastroenterologists? I do believe NOTES has a role and that surgeons should lead the way. I've operated on enough peri-umbo incisional hernias from "uncomplicated" lap choles to know that even the simple day surgery lap chole doesn't mean the patient is out of the woods. It also may mean - reop for incisional hernia, mesh placement, infected mesh, etc. Curious how many CBD injuries it will take to make peope nervous about NOTES choles however.

er's mom, the thing that sticks out in my mind every time I read about this "route" is the possibility of causing sexual dysfunction. That would seem to me to be a rather serious side-effect which has gotta be far less likely with the traditional laparoscopy. I mean, I've heard of mothers complaining of pain during intercourse years after having their babies. (I won't know that particular "joy" because both of my babies were born via c-section, first due to fetal distress and second due to breech presentation during a TOLAC.) Wouldn't sexual dysfunction be a possible risk of this procedure?

I had a tubal ligation about eight hours after the birth of my seventh baby and my ob/gyn did it through a lap incision at my navel. That was in 1970. No post-op pain, no complications of any kind. And the scar disappeared completely within, I don't know...a couple of years? I would NEVER allow abdominable surgery THROUGH my vagina! Have those docs doing it offered appendectomies or whatever to men going up through their penises? I'll bet not!

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